No name HIV Test Form 1 new version

HIV TEST FORM
Printed Barcode

PART 1
Form Approved: OMB No. 0920-0696, Exp. Date: 08/31/2010

Agency

Session Date (MMDDYYYY)

Unique Agency ID Number

Intervention ID
MMDD

Site ID

.

Site Type

Intervention
ID
Site Zip Code

(See codes on reverse)

Client ID

L

Hispanic or Latino
Not Hispanic or Latino
Don’t know
Declined

Current Gender
Male
Female
Transgender – M2F
Transgender – F2M

Black/African American
Native HI/Pac. Islander

L

White
Don’t know

State

Zip Code

County

Previous HIV Test?
Self-Reported Result
Yes
Positive
Indeterminate
No
Don’t know
Negative
Don’t know
Declined
Prelim. Pos.
Declined
Not asked
Not asked Provide date of last test (MMYYYY)

L

Race – Check all that apply
American Ind./AK Native
Asian

Ethnicity

Client

Date of Birth (MMDDYYYY)

Declined

Sample Date
(MMDDYYYY)

Source
Test
Election

Tested anonymously
Tested confidentially
Declined testing

Tested anonymously
Tested confidentially
Declined testing

Tested anonymously
Tested confidentially
Declined testing

Test
Technology

Conventional
Rapid
Other

Conventional
Rapid
Other

Conventional
Rapid
Other

Specimen
Type

Blood: finger stick
Blood: venipuncture
Blood spot
Oral mucosal transudate
Urine

Test Result

Positive/Reactive
NAAT-pos
Negative

Result
Provided

HIV TEST 1

Yes

HIV TEST 2

Blood: finger stick
Blood: venipuncture
Blood spot
Oral mucosal transudate
Urine
Indeterminate
Invalid
No result

No

Positive/Reactive
NAAT-pos
Negative
Yes

HIV TEST 3

Blood: finger stick
Blood: venipuncture
Blood spot
Oral mucosal transudate
Urine
Housing Status in the Past 3 months –
Check all that apply
Indeterminate
Indeterminate
Positive/Reactive
Invalid
Invalid
NAAT-pos
No result
No result
Negative

L

HIV Test Information

Worker ID

Yes

No

No

If results not
provided,
why?

Declined notification
Did not return/Could not locate
Obtained results from another agency

Declined notification
Did not return/Could not locate
Obtained results from another agency

Declined notification
Did not return/Could not locate
Obtained results from another agency

If rapid
reactive, did
client provide
confirmatory
sample?

Yes
Client declined confirmatory test
Did not return/Could not locate
Referred to another agency
Other

Yes
Client declined confirmatory test
Did not return/Could not locate
Referred to another agency
Other

Yes
Client declined confirmatory test
Did not return/Could not locate
Referred to another agency
Other

Choose one if:

Client was not asked about risk factors

Client was asked, but no risk was identified

Client declined to discuss risk factors

If client risk factor information was discussed, please mark all that apply:
...without using a condom?
In past 12 months has client had:
Injection Drug Use (IDU)
Vaginal or Anal Sex
With Male
With Female

Oral Sex

...with person who is an IDU?

if marked

Did client share drug injection
equipment?

...with person who is HIV positive?

Session Activity

.

(see codes on reverse)

CDC Use Fields

Local Use Fields

During this visit, was a risk reduction plan developed
Yes
for the client?
Other Session Activities (see codes on reverse)

.

Other Risk Factor(s)

Has client used injection drugs in
past 12 months?

...with person who is MSM?

L

L

Risk Factors

Date Provided
(MMDDYYYY)

No

L1

C1

L2

C2

Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB
Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600
Clifton Road NE, MS D-79, Atlanta, Georgia 30333; ATTN: PRA 0920-0696.
CDC 50.135a (E), 10/2007
WHITE COPY = Scan
YELLOW COPY = Record Keeping

HIV TEST FORM
Place Barcode Sticker
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PART 2
Form Approved: OMB No. 0920-0696, Exp. Date 08/31/2010

CDC requires the following information on confirmed positives
Was client referred to medical care?
Yes
No

L

L

If yes, did client attend the first
appointment?

Yes

If no, why?

Don’t know

No

Client already in care
Client declined care
Was client referred to HIV Prevention services?

Referrals

Yes
No

LA

Was client referred to PCRS?

L

Yes
No
If female, is client pregnant?
If yes, in prenatal care?
Yes
Yes
No
No
Don’t know
Don’t know
Declined
Declined
Not asked
Not asked

If no, was client referred
for prenatal care?
Yes
No

If yes, did client attend first
prenatal care appointment?
Yes
No
Don’t know

Local Use Fields
L8

L13

L4

L9

L14

L5

L10

L15

L6

L11

L16

L7

L12

L17

CDC Use Fields
C3

C6

C4

C7

C5

C8

L

L

L3

Notes (Print Only)

Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB
Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600
Clifton Road NE, MS D-79, Atlanta, Georgia 30333; ATTN: PRA 0920-0696.
CDC 50.135b (E), 10/2007
WHITE COPY = Scan
YELLOW COPY = Record Keeping